Treating Trauma on a Grand Scale

The fifth anniversary of the World Trade Center's collapse on 9/11, the second of the Indian Ocean tsunami, and the first anniversary of Hurricane Katrina's devastation of New Orleans recently put the issue of disaster preparedness back in the headlines. But despite a growing body of research and experience, the best way to be ready for the mental health effects of disasters is still unclear. “This is a field that is just coming of age,” says Barbara Lopes Cardozo, a psychiatrist at the Centers for Disease Control and Prevention. A surge of new publications on disaster psychiatry in prestige journals is providing new data and insights.

Craig Katz of the Mount Sinai School of Medicine was part of a team providing services to rescue workers from 9/11. They found that half the patients answered mental health questionnaires in a way that triggered a follow-up exam, and half of those needed and accepted treatment. “We were surprised to see in the years that followed that those numbers never dropped off and the need never dropped off.”

Researchers studying American soldiers have documented cognitive changes in healthy troops before and after deployment to Iraq, including the development of deficits in attention, learning and memory. But the same soldiers demonstrate an improvement in reaction time, suggesting they cannot shake off the state of hypervigilance their duty in hostile territory required. Although these mental changes fall short of clinical diagnosis of mental disorder, they may set the stage for later problems.

Katrina provided lessons about how the entire mental health support system can collapse, even in rich, developed countries. Victims who saw and suffered enormous losses from the storm had new acute mental health needs. At the same time, many mental health workers had fled the area.

Cardozo and her colleagues looked at rates of post-traumatic stress disorder (PTSD) in adults and children after the tsunami. In adults, rates of PTSD declined significantly between two and nine months after the waves hit, but rates in children did not decline, suggesting they are at heightened risk for later psychiatric problems.

Most experts agree that the field next needs to move from epidemiology to interventional trials, trying different techniques to treat victims and monitoring the effect on mental health in the long term. But they are less confident that the current interest will translate into sustained support for large-scale trials. “In public health, mental issues are given less priority than physical ones. And in policy work, interest in disaster planning is episodic,” Katz says.